questionnaire (confidential)

	University Hospital of Zurich Neuropsychology Unit
	PD Dr. Peter Brugger

Your Gender:

woman man

Age:

years

Your handedness:

ever right-handed
switched to right-handed

left-handed

ambidextrous

Years of basic schooling:
(without apprenticeship, university etc.)

years

Apprenticeship as:

University degree in:

Currently employed as:

Any comments?

unemployed

Age of your mother at your birth:

years

What nationalities are there in your ancestry?

Marital status:

single married divorced widowed

number of children:

Sexual orientation:

heterosexual

homosexual

other:

Body part(s), you would like to have amputated/rendered dysfunctional:

left arm

right arm

left leg

right leg

other:

Please provide more details (desired length of stump, special sensations in non-desired limbs, etc):

If spinal cord dissection desired, at which height?

Any other disability desired:

Since when have you been living with a desire for amputation/paraplegia?

Was there any eliciting event?

How would you describe the “differentness” of the body part you wish to have amputated? (if possible, in comparison to the corresponding member on the other side of the body, or to a part you would not like to have amputated)

What fits best the body part you would like to have amputated:

it does not belong to my person
it does not belong to my body
it feels different from the rest

Was there ever any change with respect to the non-desired body part(s)?

no
yes, shift of the demarcation line of the amputation, i.e. ...
yes, change in the body part for which amputation is desired, i.e. ....
yes, ....
...i.e.

Have you ever made an attempt to amputate/have amputated the non-desired body part?

no
yes, ...

How large would you estimate the chance that you will have reached your goal of a successful amputation within the next 5 years?


0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%

Suppose you already have had your desired amputation. How large would you estimate the chance that you developed a new desire to have another body part removed?


0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%

How large would you estimate the chance that your desire of amputation will have been permanently removed within the next 5 years?
(without realization of the amputation itself)


0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%

How often do you remember your dreams?

Approximately:

	times per	week
	.	month
		year

Have you ever dreamt yourself amputated (paralyzed/disabled) ?

no yes, once or twice ca. 5 times ca 10 times more frequently, ca. times

I would be happy to read a brief description of such a dream!

Have you considered the possibility that the presence of phantom sensations, should you succeed in getting the amputation/paraplegia, could prevent the fulfillment of your desire?

Yes. I came to the conclusion that ...

No. Now that I am asked, I think that ...

If you had reached the goal of the desired amputation, would you consider wearing a prosthesis?

yes no
any comment?:

Suppose you had the choice between two highly reliable specialists, A and B. A could perform the amputation/operation you desire without any adverse side-effects. B could take away your desire for amputation permanently, leaving everything else as is. Whom would you select?

A B
any comment?:

Was this your first contribution to a scientific study / survey on BIID (amputation desire)?

yes no, I have participated...

Do you have any further comments ?

Would you participate in an in-depth investigation of BIID?
(multiple selections possible)

no
yes, behavioral assessments
yes, brain scanning (functional magnetic resonance imaging)
yes, immersion of the outer ear canal with water
yes, magnetic stimulation of the brain (TMS)
yes, I am particularly interested in ...

These investigation would require that you travelled to Zurich (Switzerland) and/or Milano (Italy). Travel costs and accomodation would be provided.
If "yes" to any of the above questions, how could we contact you?

Finally, I would like you to rate the statements below. Please tick the mark according to how well an item describes your current personal feelings. Watch out for the negative formulations and do respond to all 12 questions, please. If your desire does not target an amputation (but a spinal cord injury, or any other disability), please imagine the term "amputation" ("amputated" etc.) exchanged by the appropriate expression. You may add comments to single items at the end of the list.

(1) My desire for amputation is so strong that it determines my life